Sedgewood Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Falmouth, Maine.
- Location
- 22 Northbrook Dr, Falmouth, Maine 04105
- CMS Provider Number
- 205159
- Inspections on file
- 16
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sedgewood Commons during CMS and state inspections, most recent first.
Surveyors found that staff did not consistently monitor or document medication refrigerator temperatures as required by CDC guidelines, with significant gaps in twice-daily temperature logs over a three-month period. This deficiency was confirmed through record review and staff interviews.
Surveyors found widespread deficiencies in housekeeping and maintenance, including off-track privacy curtains, misaligned closet doors, stained and damaged bathroom fixtures, and strong urine-like odors in multiple rooms and common areas. These issues compromised resident privacy and comfort, and were confirmed by facility leadership during an environmental tour.
An unsecured container of CaviWipes, a chemical cleaning product, was found on a bedside table in a resident's room. The SDS for CaviWipes details health hazards if improperly handled, and the product should not have been accessible in resident care areas, indicating a failure to maintain a hazard-free environment.
The facility failed to correct previously cited deficiencies, as surveyors again found that medication refrigerator temperatures were not monitored daily and that infection control protocols, specifically Enhanced Barrier Precautions, were not properly implemented. These issues persisted despite prior identification and a plan of correction.
A resident with a history of chronic diarrhea and prior C-diff colonization developed acute symptoms consistent with infectious diarrhea, but staff did not initiate transmission-based precautions or notify clinical leadership as required by policy. CNAs observed concerning changes but were told not to use precautions, and no signage or PPE was present. The Infection Preventionist and provider were unaware of the resident's condition until informed by surveyors, resulting in delayed infection control actions.
The facility did not issue written transfer or discharge notices to two residents or their legal representatives before transferring them to an acute care hospital. Documentation for both cases lacked evidence of the required notifications, and this was confirmed by the Market Clinical Advisor during the survey.
Two residents who were transferred to an acute care hospital did not receive written bed hold notices, nor did their family members or legal representatives. Review of clinical records and staff interviews confirmed the absence of required documentation at the time of transfer.
The facility failed to properly manage controlled substances, resulting in a medication error where a resident received another's morphine. The morphine bottle was not removed from use immediately, and the error was not documented. Additionally, controlled substances were logged by only one staff member, contrary to policy requiring two. This was confirmed by the Administrator and Unit Manager.
The facility failed to provide adequate housekeeping and maintenance services in two of three units. Observations included dirty shower chairs, cracked tiles, peeling wallpaper, and unlabeled urinals. The Director of Maintenance confirmed these findings.
The facility failed to complete annual performance evaluations for three CNAs. CNA #3, CNA #4, and CNA #5 had not received annual evaluations for multiple years, as confirmed by the Administrator, Clinical Market Advisor, and Market President.
The facility failed to properly store medications and biologicals in two out of three medication room refrigerators. In the [NAME] House, a dormitory-style refrigerator with a freezer was used to store vaccines, and an out-of-range temperature was recorded without appropriate follow-up actions. In the [NAME] House, two opened and unlabeled vials of PPD were found, and the refrigerator had significant ice buildup, leading to incorrect storage of various vaccines.
The facility failed to maintain the kitchen in a clean and sanitary manner and did not record food temperatures during meal preparation. A surveyor observed dust, debris, and staining on ceiling vents, and a sticky, dusty film on flat surfaces. Additionally, there was no documentation of food temperatures being taken during several meals.
The facility failed to provide residents and/or their representatives with the required Vaccine Information Statements (VIS) for the pneumococcal vaccines (PCV13, PCV15, and PCV20) prior to immunization. The omission was confirmed by the Infection Preventionist and the Marketing Clinical Advisor, who acknowledged that only the VIS for PPSV23 was being provided.
The facility failed to ensure residents and their representatives received education on the benefits, risks, and side effects of the COVID-19 vaccine before immunization. Additionally, staff were not provided formal education on the vaccine. The Infection Preventionist, Nurse Practice Educator, and Marketing Clinical Advisor confirmed the lack of educational materials and documentation, leading to the identified deficiency.
The facility failed to provide required training on Resident Rights for two CNAs, as confirmed by the Clinical Market Advisor. Both CNAs, hired in December 2023, had no documented training on this essential topic.
The facility failed to coordinate PASRR Level I and Level II assessments for a resident with Dementia and PTSD. The clinical record lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority. This was confirmed by the facility's Social Worker during an interview.
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment. A resident stated that he/she was not invited or did not remember having care plan meetings. A review of the resident's medical record revealed that MDS Quarterly assessments were completed, but there was no evidence that a care plan meeting had been held by the IDT after these assessments. This finding was confirmed by a Licensed Social Worker.
The facility failed to meet the personal hygiene preferences for a resident dependent on staff for ADL. The resident was observed with an unshaven face and long fingernails, despite expressing a preference for being clean-shaven. The CNA and Unit Manager confirmed the lack of specific documentation for completed nail care or shaving.
A facility failed to provide appropriate treatment for a resident's skin condition, as nursing staff did not identify or document a rash despite the resident's representative bringing in a cream from a dermatologist. The care plan's instructions to observe and report skin abnormalities were not followed, and the issue was only addressed after surveyor intervention.
The facility's Quality Assurance Committee failed to ensure the effectiveness of the POC for a deficiency related to housekeeping and maintenance services. Despite the POC, a re-visit survey found ongoing concerns regarding the storage of urinals and bed pans in shared bathrooms, leading to the recitation of the same deficiency tag F584.
Failure to Monitor and Document Medication Refrigerator Temperatures
Penalty
Summary
Surveyors identified that the facility failed to consistently monitor and document temperature controls for medication and vaccine refrigerators in two medication storage rooms. During observations, it was noted that these refrigerators contained various vaccines and multi-use vials, including Pneumococcal 20, influenza vaccinations, and Tuberculin Purified Protein. Review of the facility's temperature logs for the months of March, April, and May revealed significant gaps in documentation, with many days lacking evidence of the required twice-daily temperature readings. Specifically, one refrigerator was missing readings for 15, 24, and 25 days in March, April, and May, respectively, while another refrigerator was missing readings for 31, 28, and 30 days in the same months. During interviews, facility staff confirmed the findings and stated that they follow CDC guidelines for vaccine and medication storage, which require temperature checks and documentation at least twice daily. The lack of consistent temperature monitoring and documentation was confirmed by both the surveyor's review and staff interviews, indicating noncompliance with accepted professional standards and CDC guidelines for medication and vaccine storage.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain adequate housekeeping and maintenance services, resulting in unsanitary, disordered, and uncomfortable conditions in 36 out of 56 resident rooms and across all three units. Specific deficiencies included room divider curtains and window curtains being off track and unable to fully close, which compromised resident privacy in multiple rooms. Additionally, closet doors were misaligned and did not fully close in several rooms. Other maintenance issues included holes in walls, torn wallpaper, stained ceiling tiles, and damaged bathroom fixtures such as chipped sink countertops and toilets with visible stains or improper installation. Several rooms and common areas were noted to have strong urine-like odors and uncleanable surfaces due to damage or staining. These findings were confirmed during an environmental observation tour conducted with the Administrator and Maintenance Supervisor, who acknowledged the extent of the issues. The report documents that these conditions were present throughout the facility, affecting a significant number of resident rooms and common areas, and were not limited to isolated incidents. No information was provided regarding the medical history or specific conditions of the residents affected by these deficiencies.
Unsecured Chemical Cleaning Product Found in Resident Room
Penalty
Summary
A deficiency was identified when an unsecured container of CaviWipes, a chemical cleaning product, was observed on a bedside table in a resident's room. This incident occurred during a survey of one of the facility's units. The Safety Data Sheet (SDS) for CaviWipes outlines the potential health hazards associated with exposure, including the need for medical attention in cases of inhalation, skin contact, eye contact, or ingestion. The presence of this unsecured chemical in a resident care area demonstrated a failure to ensure that the environment was free from accident hazards related to the proper storage of chemicals.
Repeat Deficiencies in Medication Storage and Infection Control
Penalty
Summary
The facility's Quality Assurance Committee did not ensure the effectiveness of the Plan of Correction for previously identified deficiencies from the Annual Long Term Care Survey Process. During a follow-up survey, it was found that the same deficiencies, specifically F761 and F880, were still present. F761 involved the failure to monitor medication refrigerator temperatures on a daily basis, while F880 pertained to the failure to maintain an Infection Control Program by not applying appropriate interventions related to Enhanced Barrier Precautions. These deficiencies were observed and confirmed through record review and interviews, and were discussed with facility leadership during the exit conference.
Failure to Implement Timely Infection Control Measures for Suspected C-diff
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for the surveillance and prevention of gastrointestinal disease transmission in one resident. Despite facility policy requiring nursing staff to initiate transmission-based precautions for suspected infectious diarrhea and to notify the attending physician and Infection Preventionist, these steps were not followed when a resident exhibited three episodes of watery stool with significant mucous and foul odor. Certified Nursing Assistants observed changes in the resident's stool consistent with previous C-diff infection but were instructed not to use transmission-based precautions, and no signage or personal protective equipment was present outside the resident's room. The resident, who had a history of chronic diarrhea and prior C-diff colonization, was not placed on precautions despite acute changes in stool characteristics. Interviews with staff revealed confusion and lack of communication regarding the need for precautions, with CNAs expressing uncertainty about protocol and reporting that they were not informed of the resident's change in condition. The Infection Preventionist and Market Clinical Advisor were unaware of the resident's acute symptoms until informed by surveyors, and the facility provider confirmed that the changes in stool warranted precautions and further testing, but they had not been notified. The failure to recognize and respond to the resident's symptoms in a timely manner resulted in a delay in implementing appropriate infection control measures.
Failure to Provide Written Transfer/Discharge Notices Prior to Hospital Transfers
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents or their legal representatives prior to facility-initiated transfers to an acute care hospital. Specifically, documentation for two residents showed that each was transferred and subsequently admitted to a hospital, but there was no evidence in their clinical records that a written notice of transfer or discharge was issued to them or their legal representatives. This deficiency was confirmed during an interview with the Market Clinical Advisor, who was unable to locate the required transfer/discharge forms for these residents at the time of their transfers.
Failure to Issue Written Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, or their family members or legal representatives, when the residents were transferred to an acute care hospital. Specifically, the clinical records for both residents showed that they were transferred and subsequently admitted to a hospital, but there was no documentation that a written bed hold notice was issued at the time of transfer. This was confirmed during an interview with the Market Clinical Advisor, who was unable to locate any evidence of the required notification in the records for either resident. The deficiency centers on the lack of written communication regarding bed hold policy to the residents or their representatives at the time of hospital transfer, as required by regulation.
Medication Management Deficiency Involving Controlled Substances
Penalty
Summary
The facility failed to maintain a proper system for handling controlled substances, leading to a medication error involving two residents. A nurse administered a dose of morphine to one resident using another resident's morphine bottle and oral syringe. This incident was not documented in the Narcotics Logbook, and the morphine bottle continued to be used for six days after the error occurred. The Unit Director was unaware that the morphine bottle had not been removed from use immediately, and there was no evidence that the oral syringe was disposed of after the incident. Additionally, the facility did not comply with its policy requiring two licensed staff members to document the receipt of controlled substances from the pharmacy. The Narcotic Logbook showed that controlled substances, including morphine and fentanyl patches, were logged in by only one staff member on multiple occasions. This was confirmed by the Administrator and the Unit Manager, indicating a systemic issue in the management of controlled drugs at the facility.
Inadequate Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for two of three units. During an environmental tour, several deficiencies were observed. In the first unit, the shower room had a laydown shower chair with an orange-colored coating under the chair edge and rim, a raised floor with cracks, and cove base peeling away from the wall. A resident's wheelchair seat was coated with dirt and debris. One bedroom door was sticking, making it difficult to open, and a wall light near another room door was missing its cover. Wallpaper was peeling and stapled to the wall in multiple locations. In the second unit, the shower room had a bariatric shower chair and laydown shower chair both with orange-colored coating under the chair edge and rim. One bathroom had cracked tiles and a black built-up substance around the base of the toilet. Another bathroom had a urine hat stored on top of the toilet, and a shared bathroom had an unlabeled urinal hanging on the toilet grab bars. The Director of Maintenance confirmed these findings during the tour.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five sampled Certified Nursing Assistants (CNAs). CNA #3, hired on 3/4/20, had their last performance evaluation as a 90-day progress report completed on 8/14/20, with no evidence of annual evaluations for 2021, 2022, 2023, or 2024. CNA #4, hired on 5/11/15, had their last performance evaluation completed on 5/3/19, with no evidence of annual evaluations for 2020, 2021, 2022, or 2023. CNA #5, hired on 7/31/18, had their last performance evaluation completed on 9/26/19, with no evidence of annual evaluations for 2020, 2021, 2022, or 2023. During an interview on 3/27/24, the Administrator, Clinical Market Advisor, and Market President confirmed that staff performance evaluations had not been completed annually.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to properly store medications and biologicals in two out of three medication room refrigerators surveyed. In the [NAME] House medication room, a dormitory-style refrigerator with a freezer was used to store influenza and pneumococcal vaccines. The recorded temperature for the refrigerator showed an out-of-range temperature of 70.8°F on 3/24/24. The Unit Manager was unaware of any actions taken following the discovery of the out-of-range temperature and could not confirm whether the vaccines were in the refrigerator at that time. Additionally, the Interim Director of Nursing (IDON) confirmed that the dorm-style refrigerator was inappropriate for storing vaccinations and that the vaccines were not removed at the time the out-of-range temperature was discovered. In the [NAME] House medication room, a surveyor found two opened and unlabeled vials of Purified Protein Derivative (PPD) used for tuberculosis testing, which should have been labeled with an open date and discarded 30 days after opening. The refrigerator also had significant ice buildup along the back inside surface and stored various vaccines, including pneumococcal, RSV, Spikevax (Covid-19), and influenza vaccines. The IDON confirmed the ice buildup and that the facility policy was not followed after the discovery of the out-of-range temperature, leading to incorrect storage of vaccinations. The facility's policy required immediate notification of maintenance and the Director of Nursing, moving medications to another refrigerator, and contacting the pharmacist for guidance, none of which were followed.
Kitchen Sanitation and Food Temperature Documentation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and did not record food temperatures during meal preparation. During an initial kitchen tour, a surveyor observed and confirmed with the cook the presence of dust, debris, and staining on the ceiling vents, as well as a sticky, dusty film on all flat surfaces in the kitchen. Additionally, there was a lack of documentation of food temperatures being taken during dinner on 3/23/24, all day on 3/24/24, all day on 3/25/24, and breakfast on 3/26/24.
Failure to Provide Required Vaccine Information Statements
Penalty
Summary
The facility failed to provide residents and/or their representatives with the Vaccine Information Statement (VIS) prior to administering the pneumococcal vaccine (Prevnar). The facility's Pneumococcal Vaccination policy and procedure, revised on 11/1/23, mandates that patients or their representatives be educated about the benefits and potential side effects of the vaccination through the VIS. However, during a review of the facility's admission packet, it was found that the VIS sheets for PCV13, PCV15, and PCV20 were missing. The Infection Preventionist (IP) confirmed that the required VIS sheets were not provided to residents or their representatives upon admission or prior to the administration of these vaccines. Further interviews revealed that the facility's Marketing Clinical Advisor also confirmed the omission of the Prevnar vaccine VIS sheets. The facility was only providing the Pneumococcal Polysaccharide vaccine (PPSV23) VIS sheet, neglecting to include the necessary VIS sheets for the other pneumococcal vaccines (PCV13, PCV15, and PCV20). This oversight led to residents and/or their representatives not receiving the required information about the risks and benefits of the vaccines before immunization.
Failure to Provide COVID-19 Vaccine Education to Residents and Staff
Penalty
Summary
The facility failed to ensure that each resident or their representative received education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine before immunizing residents. The facility's Infection Preventionist (IP) confirmed that the admission packet, which includes the COVID-19 vaccine education and consent form, lacked evidence of such education. Additionally, the IP admitted that staff were not provided formal education on the benefits and risks of the COVID-19 vaccine. This was corroborated by the Nurse Practice Educator (NPE), who stated that no education on COVID-19 vaccines had been conducted for staff, and a Registered Nurse (RN) in orientation confirmed she had not received any education on the new Spikevax COVID-19 vaccine. A Licensed Practical Nurse (LPN) also indicated uncertainty about receiving education on the new vaccine, typically only signing sheets when new information is released. The Marketing Clinical Advisor confirmed that residents and their representatives were not provided with the Vaccine Information Statement (VIS) education upon admission or prior to vaccine administration, and no educational materials were found in common areas of the facility. The facility's COVID-19 Vaccination policy and procedure, revised on 2/7/24, states that the facility will provide the opportunity to receive COVID-19 vaccinations following CDC recommendations and will obtain consent using the Patient Informed Consent or Declination COVID-19 form. However, the facility did not adhere to this policy, as evidenced by the lack of documented education for both residents and staff. The surveyor's interviews with various staff members, including the IP, NPE, RN, and LPN, revealed a consistent lack of formal education on the COVID-19 vaccine, specifically the new Spikevax vaccine. The Marketing Clinical Advisor's confirmation further highlighted the facility's failure to provide necessary educational materials to residents and staff, leading to the identified deficiency.
Lack of Resident Rights Training for CNAs
Penalty
Summary
The facility failed to implement and maintain an effective training program that includes training on Resident Rights for two of five Certified Nursing Assistants (CNAs) reviewed. Specifically, CNA #1, hired on 12/26/23, and CNA #2, hired on 12/4/23, had no documented training regarding Resident Rights. This deficiency was confirmed during an interview with the Clinical Market Advisor, who acknowledged the absence of documentation for the required annual training on Resident Rights.
Failure to Complete PASRR Screening
Penalty
Summary
The facility failed to coordinate assessments for Pre-Admission Screening and Resident Review (PASRR) Level I and Level II programs for a resident diagnosed with Dementia and Post Traumatic Stress Disorder. The clinical record for the resident, who was admitted to the facility, lacked evidence that the PASRR Level I Screen was forwarded to the State Mental Health Authority to determine if the resident met the State of Maine's definition of a serious mental health disorder and to determine if a Level II assessment was needed. This deficiency was confirmed during an interview with the facility's Social Worker, who acknowledged that the PASRR Level I screening had not been completed and stated they would proceed with the PASRR at that time. The finding was later discussed with the Market President.
Failure to Review and Revise Care Plan by IDT
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT) that included, to the extent possible, participation of the resident and/or his/her representative after each assessment. During an interview, a resident stated that he/she was not invited or did not remember having care plan meetings. A review of the resident's medical record revealed that Minimum Data Set (MDS) Quarterly assessments were completed, but there was no evidence that a care plan meeting had been held by the IDT after these assessments. This finding was confirmed by a Licensed Social Worker during an interview.
Failure to Meet Personal Hygiene Preferences for Dependent Resident
Penalty
Summary
The facility failed to meet the personal hygiene preferences for a resident who is dependent on staff for Activities of Daily Living (ADL). On 3/26/24, a surveyor observed Resident #49 with an unshaven face and long fingernails with a dark substance under them. The resident, diagnosed with dementia and lower extremity amputation, was assessed to need staff assistance for personal hygiene, including nail care and shaving, as per the Minimum Data Set (MDS) assessment. The Certified Nursing Assistant (CNA) confirmed that the resident had not been shaved for several days and was unsure about the last time the nails were done, acknowledging the resident's dependence on staff for these tasks. On 3/27/24, the surveyor interviewed Resident #49 and the Resident Representative, who confirmed that the resident had still not been shaved or provided nail care. The resident expressed a preference for being clean-shaven, and the Resident Representative mentioned having requested shaving several days prior. The Unit Manager confirmed that there was no specific documentation for completed nail care or shaving, only for refusals, and there was no record of the resident refusing these services. The Unit Manager acknowledged that residents should be shaved daily if that is their preference.
Failure to Provide Appropriate Skin Condition Treatment
Penalty
Summary
The facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for skin conditions. The deficiency was identified for a resident who had a rash and was observed scratching and itching several small, scabbed areas on the upper right arm. Despite the resident's representative bringing in a cream from a dermatologist, there was no evidence in the resident's skilled documentation from admission through the observation period that the nursing staff had identified or documented the rash. The care plan instructed nursing to observe the skin condition daily and report abnormalities, but this was not followed. The RN confirmed she was unaware of the rash and noted that skin checks are done weekly, relying on CNAs to report any concerns. The RN also acknowledged the need for a provider order to use the cream brought in by the family. The interim Director of Nursing confirmed that the resident's rash was only assessed after surveyor intervention. The lack of documentation and timely assessment of the resident's skin condition indicates a failure to provide appropriate treatment and care according to the resident's needs and the facility's care plan. This deficiency highlights a gap in communication and adherence to care protocols within the facility's nursing staff.
Failure to Maintain Sanitary Conditions
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction (POC) for a deficiency identified during the annual Long Term Care Recertification Survey. The deficiency, cited under Federal citation F584, pertained to the facility's failure to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition. Despite the POC indicating that resident rooms and bathrooms would be in a sanitary condition by a specified completion date, a re-visit survey found ongoing concerns regarding the storage of urinals and bed pans in shared bathrooms on the [NAME] unit. These observations led to the recitation of the same deficiency tag F584.
Latest citations in Maine
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Two residents did not receive medications according to physician orders and facility expectations. One resident with PNA, COPD, and an upper respiratory infection lacked timely access to ordered Acetylcysteine and did not receive Ipratropium-Albuterol and Doxycycline doses as ordered, despite Doxycycline being available in the PIXUS automated dispensing system and the DON’s expectation that nurses use PIXUS when medications are needed before pharmacy delivery. Another resident with HTN received Metoprolol Tartrate even though the recorded BP was below the ordered hold parameter, and the DON confirmed the dose should have been held.
Staff failed to protect the confidentiality of resident health information when assignment sheets containing personal medical details were left face up and unattended on treatment and medication carts. On two separate occasions, assignment sheets listing multiple residents’ medical information were observed on unattended carts in a unit hallway, visible and easily accessible to residents, visitors, and other unauthorized individuals while various staff, ambulatory residents, and family members were nearby. An LPN later acknowledged that such assignment sheets should not be left in the open, and the issue was brought to the DON.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
A resident with MDD, anxiety, PTSD, and intact cognition, who was primarily bedbound and usually received bed baths, experienced bowel incontinence and declined a shower, requesting a bed bath and to speak with the unit manager. The unit manager was not informed of this request. After the charge nurse confirmed with leadership that there were no contraindications to a shower, the charge nurse and a CNA used a mechanical lift to place the resident on a shower chair, covered the resident with bath blankets, and transported the resident to the shower room. Despite the resident expressing fear, stating they did not feel like a shower, and later reporting crying and repeatedly saying they did not want a shower, staff proceeded with the shower. This conflicted with the resident’s expressed wishes and the facility’s policy on the right to refuse treatment, dignity, and reasonable accommodation of individual needs and preferences.
A resident admitted with a fractured leg and chronic hip and knee pain reported requesting pain medication shortly after arrival, but staff stated they were waiting for pharmacy access to the Cubex machine and the resident did not receive ordered PRN oxycodone until about eight hours later, despite a documented pain score of 6. Record review showed an active hospital discharge order for oxycodone 5 mg PO q4h PRN, but there was no documentation that staff contacted a physician for alternative pain orders or implemented non-pharmacological pain interventions such as repositioning or distraction. The DON confirmed there was no evidence of these interventions or physician contact while waiting for Cubex access.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Provide Timely Respiratory Medications and Follow Cardiac Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered respiratory and antibiotic medications in a timely manner and to follow physician orders for cardiovascular medication parameters. For one resident with pneumonia (PNA), COPD, and an upper respiratory infection, physician orders included Acetylcysteine inhalation solution as needed every 6 hours for PNA, Ipratropium-Albuterol solution four times daily for COPD, and Doxycycline Monohydrate capsules twice daily for an upper respiratory infection. Record review showed no evidence that Acetylcysteine was available or administered from the initial order date through the date it was discontinued and reordered, and that the Ipratropium-Albuterol solution was not administered per provider orders upon admission. The resident was sent to the emergency room for difficulty breathing and returned the next day. The MAR/TAR also showed that the noon dose of Ipratropium-Albuterol and the nighttime dose of Doxycycline were not given until after the resident’s return, despite Doxycycline 50 mg capsules being available in the facility’s PIXUS automated dispensing system. The DON stated that nurses are expected to use PIXUS when medications are needed before pharmacy delivery and acknowledged that two 50 mg capsules should have been used to provide the ordered evening dose. For another resident with hypertension (HTN), a physician ordered Metoprolol Tartrate 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the MAR/TAR showed that on one evening the Metoprolol Tartrate was administered despite a recorded blood pressure of 95/56, which was outside the ordered parameters. In an interview, the DON confirmed that the Metoprolol should have been held in accordance with the physician’s order parameters.
Failure to Protect Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information when staff assignment sheets containing residents’ personal medical information were left unattended and visible on treatment and medication carts. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff member’s assignment sheet placed face up, displaying personal medical information for ten residents. The sheet was visible and easily accessible to residents, visitors, and unauthorized personnel, while Environmental Services staff and CNAs were nearby. A Licensed Practical Nurse later confirmed that the assignment sheet should not have been left in the open and should have been secured. Later that same day, from 3:35 p.m. to 3:41 p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with another staff member’s assignment sheet on it, also face up, containing personal medical information for four residents. This sheet was similarly visible and easily accessible to residents, visitors, and unauthorized personnel, with Environmental Services staff, CNAs, ambulatory residents, and residents’ family members in the area. The issue was subsequently discussed with the Director of Nursing.
Failure to Provide Required Written Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written bed-hold and transfer/discharge notices for a facility-initiated transfer of one resident to an acute hospital. Record review showed that the resident was transferred on 3/8/26 and subsequently admitted to the hospital, but the clinical record contained no evidence that a written bed-hold notice or a transfer/discharge notice was issued to the resident or the resident’s legal representative. This lack of documentation regarding the resident’s bed-hold rights and transfer/discharge information was confirmed with the Director of Nursing on 3/23/26 at 1:30 p.m. The deficiency centers on the absence of written notification related to the resident’s needs, appeal rights, or bed-hold policies at the time of the facility-initiated transfer/discharge to the acute care setting, as required by regulation, for 1 of 3 sampled residents who experienced such transfers.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Resident’s Refusal of Shower and Preference for Bed Bath Not Honored
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to refuse care and choose their preferred method of bathing. After an episode of bowel incontinence, staff asked the resident if they wanted a shower, and the resident declined, requesting a bed bath and to speak with the unit manager. The unit manager was in a clinical meeting and was not made aware of the resident’s request. The charge nurse interrupted the meeting, asked leadership if there was any reason the resident could not have a shower, and was told there were no known contraindications. The charge nurse then informed the resident that management was okay with the resident having a shower, and staff proceeded with preparations for a shower despite the resident’s prior refusal and request for alternative care. The resident, who had diagnoses including Major Depressive Disorder, Anxiety, and PTSD and a BIMS score indicating intact cognition, was primarily bedbound and typically received bed baths, with the care plan later revised to specify bed baths only per request. A CNA and the charge nurse used a mechanical lift to transfer the resident onto a shower chair, covered the resident with bath blankets, and transported the resident down the hall to the shower room. According to the CNA, the resident expressed fear and said not to push or take them down, and again said they did not feel like a shower, but the CNA encouraged the shower as being quick. The resident reported being placed naked on a sheet, transported down the hall, and bathed while crying, yelling, and repeatedly stating they did not want a shower, and later described hating the experience and continuing to have nightmares. The facility’s own policy states that residents have the right to refuse treatment, to have their dignity maintained, and to have their needs and preferences reasonably accommodated, which was not followed in this incident.
Failure to Provide Timely Pain Management for New Admission
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted with a fractured left leg and chronic hip and knee pain. After discharge from the hospital, the resident arrived at the facility at approximately 2:50 p.m. and requested pain medication. The resident reported being told that their medications had not yet arrived from the pharmacy and that staff were waiting for a code from the pharmacy to access the Cubex automated medication dispensing machine for narcotics. Review of the hospital discharge orders showed an order for Oxycodone 5 mg by mouth every 4 hours as needed for pain for 14 days. The admission nurse’s note documented the resident’s pain level as 6 on a 1–10 scale. Review of the Medication Administration Record showed that the resident did not receive the ordered Oxycodone until 11:05 p.m., approximately eight hours after the initial request for pain medication, with a documented pain level of 6 at the time of administration. There was no documentation in the clinical record that staff attempted to contact a physician for alternative pain medication orders while waiting for access to the Cubex machine. Additionally, there was no documented evidence that non-pharmaceutical pain interventions, such as repositioning, distraction activities, or discussing prior effective pain relief methods with the resident, were attempted. In an interview, the DON confirmed there was no evidence of non-pharmaceutical interventions or attempts to contact a physician during this period.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
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